If you are located within a commutable drivable distance (no more than 1 hour) from Metro Orlando Florida, Volusia County, or Brevard County , you will have the flexibility to telecommute* (work from home) as you take on some tough challenges.

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are ill-equipped to navigate our overwhelming healthcare system.

Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.

At Landmark , our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health, and other employed team members.

Join Landmark to be part of a growing company full of purpose-driven, action-oriented, and compassionate team members working to dramatically transform healthcare for our communities.

OBJECTIVE

The Transition of Care Coordinator (TOCC) is a critical member of the Landmark Interdisciplinary Team (IDT). Reporting to the Health Services Director or Manager, this role will assist with standardizing the post-acute care process by tracking and managing the market’s census and post-acute statuses for the engaged and non-engaged patients. The TOCC will also support the market leadership team, Landmark clinicians, and other members of the IDT with important operational and clinical tasks, as well as proactively outreaching to local facilities to verify patient records and care statuses. The ideal candidate will draw on their critical-thinking skills, clinical experience, and positive attitude to coordinate with and support Landmark patients and Landmark team members in a fast-paced and evolving environment.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position is full-time Monday - Friday . Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00am – 5:00pm EST. It may be necessary, given the business need, to work occasional overtime, holiday, and weekend.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

COMPETENCY

To perform the job successfully, an individual should demonstrate the following competencies:

• Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics.
• Technical Skills - Assesses own strengths and weaknesses; pursues training and development opportunities; strives to continuously build knowledge and skills; shares expertise with others.
• Dependability - Follows instructions, responds to management direction; takes responsibility for own actions; keeps commitments; commits to long hours of work when necessary to reach goals; completes tasks on time or notifies appropriate person with an alternate plan.
• Initiative - Volunteers readily; undertakes self-development activities; seeks increased responsibilities; takes independent actions and calculated risks; looks for and takes advantage of opportunities; asks for and offers help when needed; generates suggestions for improving work and workflow.
• Attendance/Punctuality - Is consistently at work and on time; ensures work responsibilities are covered when absent; arrives at meetings and appointments on time.
• Interpersonal Skills - Focuses on solving conflict; maintains confidentiality; listens to others; keeps emotions under control and overcomes resistance when necessary; remains open to new ideas.
• Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and seeks clarification; responds openly to questions. Must be able to deal with frequent change, delays, or unexpected events

Primary Responsibilities:

• Collate all ADT (admit/discharge/transfer) data from various data sources
• Input real-time patient data into Landmark’s homegrown EHR system
• Manage internal reports to track transition of care data and post-discharge metrics
• Coordinate appropriate post-acute process with Landmark Providers and Nurse Care Managers
• Maintain regular contact with local hospitals and care facilities to collect clinical data and verify patient statuses
• Maintain local Health Information Exchange (HIE) relationship and access
• Handle escalated patient issues, ensuring the appropriate resources are involved
• Follow triage protocol when needed
• Other duties as assigned

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School Diploma / GED (or higher)
• Knowledge and proficiency MS Excel (open, edit/add updates, filter/sort data) Outlook (read/respond to email) PowerPoint (ability to create and/or edit a presentation)
• Ability to work full-time, Monday - Friday between 8:00am – 5:00pm EST including the flexibility to work occasional overtime and weekend (holiday) given the business need

Preferred Qualifications:

• Bachelor’s Degree (or higher)
• Experience as a Patient Navigator, Medical Assistant, Pharmacy Tech, or other clinical or administrative role in a health care setting
• Experience with data collation and working with triage

Soft Skills:

• Work independently with minimal supervision
• Communication skills (verbal/written)
• Critical Thinking & Analytical skills

Telecommuting Requirements:

• Reside within a commutable drivable distance (no more than 1 hour) from Metro Orlando Florida, Volusia County, or Brevard County
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Ability to keep all company sensitive documents secure (if applicable)
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies required all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers with Optum . Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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